Chinese officials have reported that the country’s fifth outbreak of the H5N1 avian flu this year is killing chickens in poultry markets in the southern city of Guangzhou. Although this particular outbreak is not known to have affected humans, China has already reported three human avian-flu deaths this year. Far more worrisome is the April 3 confirmation by the government of Pakistan and the World Health Organization of three cases in a family cluster in Pakistan’s North West Frontier Province late last year, suggesting limited human-to-human transmission.


Public health officials world-wide are concerned that eventually the highly virulent H5N1 flu, which now primarily affects birds, will mutate into a form readily transmissible from human to human. This transformation is made more likely by the cultural and animal husbandry practices that are prevalent throughout much of Asia, where domesticated fowl live (and are slaughtered) in close proximity with human populations.

Some critics have decried what they consider to be wealthy countries’ selfish attitude toward preventing and responding to a pandemic of H5N1 avian flu, proposing instead a major effort to improve health practices in Asia, where a pandemic strain would likely arise. However, the close proximity of billions of poultry and swine to humans, combined with unsanitary conditions, poverty and a grossly inadequate public-health infrastructure of all kinds, make it doubtful that a pandemic could be prevented or contained at the source.

It is noteworthy that China’s prodigious effort to vaccinate 14 billion chickens annually has been chaotic, compromised by the appearance of significant amounts of counterfeit vaccines and by the absence of protective gear for vaccination teams—who might actually spread disease by carrying fecal material on their shoes from one farm to another.

In theory, it is possible to contain a flu pandemic in its early stages by performing “ring prophylaxis”—using anti-flu drugs and quarantine aggressively to circumscribe and isolate relatively small outbreaks of a human-to-human transmissible strain of H5N1. Although ring prophylaxis might work in Minneapolis, Toronto or Zurich, in the parts of the world where flu pandemics begin the probability of success approaches zero. In places like Vietnam, Indonesia, and China—where the pandemic strain will likely originate—expertise, coordination, discipline and infrastructure are lacking.

If national governments are incapable of appropriate, timely actions to prevent or respond to a potential pandemic of avian flu, to whom could we delegate responsibility? The World Health Organization? Sadly, the WHO is a component of the scientifically challenged, unaccountable United Nations, which gave us the Iraq oil-for-food scandal and a botched investigation into the assassination of Lebanese politician Rafik Hariri. It’s hard to believe the U.N. would keep politics out of scientific and medical decisions.

Anti-flu drugs are extremely expensive and in short supply. If we were to supply them to poor countries for ring prophylaxis, history tells us that the medicines often would be administered improperly—such as in sub-optimal doses—in ways that would promote viral resistance and only intensify a pandemic. Or perhaps sold on the black market to enrich corrupt government officials.

A politically incorrect but more rational strategy would be for the richer countries to devote resources to developing countries primarily for surveillance, in order to obtain timely warning of the existence of an H5N1 strain that is transmissible from human to human, but to focus the vast majority of their funding on a variety of low- and high-tech approaches—vaccines, drugs, and other public health measures—that will primarily benefit themselves.

If the pandemic were to begin relatively soon—say, within a year or two—there would be little that could be done to attenuate significantly the first wave of infections. (If we’re ready to rush the pandemic strain into a crash program to manufacture vaccine, we could possibly blunt the second wave, however.)

A flu pandemic will require triage on many levels, including not only decisions about which patients are likely to benefit from scarce commodities such as drugs, vaccines and ventilators, but also broader public policy choices about how—among literally a world of possibilities—best to expend resources.

ABOUT THE AUTHOR

Dr. Henry I. Miller is an academic researcher, author and commentator. He graduated from the Massachusetts Institute of Technology with a Bachelor of Science degree in Life Sciences and attended the University of California, San Diego, receiving the M.S. (Molecular Biology) and M.D. degrees. After completing his clinical training in internal medicine as a Clinical Fellow in Medicine at Harvard Medical School, Dr. Miller was a Research Associate in the laboratory of Philip Leder at the National Institutes of Health. Dr. Miller joined the FDA in 1979 and served in a number of posts involved with the new biotechnology, among them Special Assistant to the FDA Commissioner and founding director of the FDA's Office of Biotechnology. During his government service, Dr. Miller wrote and lectured frequently on the regulatory requirements for biotechnology products, and participated frequently on various expert and policy panels as a representative of the FDA or the US government. As the FDA's contact person for the Securities and Exchange Commission, he reviewed the accuracy of claims made by companies in their prospectuses about the likelihood and timing of drug approvals. Dr. Miller is currently at Stanford University, where he is a fellow at the Hoover Institution. His research focuses on the relationship between science and regulation, the costs and benefits of government regulation, models for regulatory reform, and federal and international oversight of biotechnology. Other research areas include various aspects of bioterrorism and the need for better oversight of nutritional supplements. Dr. Miller is the author of more four hundred articles in scholarly and popular publications. He writes frequently for such publications as the Financial Times (London), Wall Street Journal, Los Angeles Times, Chicago Tribune, Washington Times, Biotechnology Law Report, Trends in Biotechnology, and Nature Biotechnology. He is the author of Policy Controversy in Biotechnology: An Insider ' s View (R.G. Landes Co. and Academic Press, 1997) and ' To America ' s Health: A Proposal to Reform the Food & Drug Administration ' (Hoover Institution Press, 2000). Dr. Miller is a director of Consumer Alert, a national consumer advocacy organization; a director of the American Council on Science and Health; an Adjunct Scholar at the Competitive Enterprise Institute; and a scientific advisor to the George C. Marshall Institute.